Let's face it - traditional dental insurance isn’t what it used to be. When dental insurance first emerged in the early 1950s, it was a beacon of hope for many individuals and families seeking cost savings toward their dental care. Back then, the average annual maximum was the same as it is for most plans today - around $1,000 to $1,500. That would cover a substantial portion of treatment in those days, especially considering that the average cost of a dental crown was around $50 to $100.
Fast forward to today, and dental insurance looks very different. Many patients today feel they should be able to depend on their dental insurance to cover the costs associated with their dental care. However, what many patients don't realize is that modern day dental insurance can often be more of a hindrance than a help when it comes to receiving high-quality dental care.
Despite the rising costs of dental care, dental insurance has failed to keep pace with inflation and cost of living. Most insurance plans today continue to offer the same annual maximums they did over 70 years ago, effectively leaving patients underinsured and struggling to afford essential treatment. Had insurance kept up with inflation and cost of living, the annual maximum today should be around $10,000. In a world where basic dental procedures can easily cost $1,000 or more, an annual maximum of $1,000 to $1,500 falls painfully short of meeting the needs of most patients.
So, what's the deal with dental insurance?
Here, we delve into some of the limitations of dental insurance, and how it could actually be having a negative impact on your dental health.
One of the most significant drawbacks of dental insurance is the annual maximum limit. Unlike medical insurance, which can cover a significant portion of medical expenses, dental insurance typically has an annual cap that hasn't significantly increased in decades. This cap is often around $1,000-$1,500 per year, which is barely enough to cover routine x-rays, checkups, cleanings and perhaps one major procedure. Patients requiring anything more than very simple dental treatment can very quickly exceed this annual limit and end up being left on their own to pay for the portion of their treatment not covered by their insurance.
2. Narrow Scope of Covered Procedures:
Most dental insurance plans typically cover preventative care like x-rays, exams and cleanings, as well as some more basic procedures like fillings and extractions. However, more complex and costly procedures such as periodontal treatment, complex fillings, crowns, bridges, root canals, implants, dentures and orthodontic treatment often have limited or no coverage. This limitation in coverage often puts patients in a difficult situation where they need to choose between doing what's right and doing what they can afford, which aren't always the same thing. This can result in some patients choosing only what they can afford vs. what's really the best possible treatment option for their dental health. For example, one of the saddest and most difficult things for me as a dentist is to hear from a patient that they chose to extract one or more teeth simply because it was the most affordable option for them at the time, instead of going through with other treatment options that would have otherwise allowed them to keep their tooth/teeth. In this day and age, with all of the advances we've seen in dentistry and all of the knowledge and expertise available to us, losing a tooth should always be a last resort decision. Not one made by a patient who feels that's their only choice due to being left uncovered by their insurance.
3. Waiting Periods and Pre-Existing Condition Clauses:
Contracts for many dental insurance plans include specific language that prohibits patients from receiving the care they need either for a specific period of time (referred to as a "waiting period") and/or due to underlying dental concerns that are present at the time of enrollment. Requiring patients to wait for 6 months or sometimes even longer can result in their dental health becoming significantly worse during that time period. This can put patients at an increased risk for dental pain and infection, some of which can even be life-threatening. Some patients with pre-existing conditions may also find themselves denied for the treatment they need even after enrolling and waiting for their insurance coverage to become active. These exclusions can be very limiting and frustrating for patients with chronic dental concerns who need immediate or continuous care.
4. Waiting Periods for Major Treatments:
As mentioned above, another common feature of many dental insurance plans is the waiting period, which is often required for more complex/major procedures. In some cases, patients may need to wait several months, or even up to a year, before their insurance will even consider covering procedures like root canals, crowns, bridges, implants, etc. This delay in treatment can cause dental concerns to become even worse, often resulting in pain, infection, and the need for more extensive and costly dental treatment later on down the line.
5. Network Restrictions and Provider Limitations:
Most dental insurance plans restrict patients to a "network" of "preferred" providers. Dental insurance carriers are intentionally very careful about the wording they use. They use terms like "in-network" and "preferred provider" vs. "out-of-network" or "restricted provider" to lead patients to believe that they'll be more protected and better off seeing an "in-network" provider vs. an "out-of-network" provider. The truth is, patients actually have the freedom to choose any healthcare provider of their choosing. While most dental insurance carriers will try to sway patients in the direction of one of their "in-network" or "preferred" providers, patients can ultimately choose to go wherever they'd like to receive the kind of care and experience they'd prefer. It's worth noting that not all "in-network" or "preferred" providers are inherently bad providers. In fact, there's a very good chance that most of these providers are in fact very skilled and provide very high-quality care. However, patients should understand some key differences between an office or provider that's in-network vs. one that isn't.
In-network providers sign contracts with dental insurance carriers. In doing so, they become part of an insurance "network" and are promised access to a large volume of patients covered by each specific insurance carrier. In exchange, these "in-network" providers agree to practice dentistry according to the terms and conditions outlined by each insurance carrier. These terms and conditions are often very strict and limiting. They can make it exceptionally difficult for dental providers to provide the kind of care they want, use the kind of materials they want, or provide the overall experience they want.
One of the biggest sacrifices these in-network providers make is agreeing to be contractually obligated to be paid only what each insurance carrier determines to be a "fair" fee for each service provided. This means that providers are paid significantly less for the care they provide and the time the spend doing so. In these cases, the main benefit to patients is typically that their insurance often covers more of the cost of their care since they limit how much a provider can be paid for providing it. This often results in fewer out-of-pocket expenses for patients. Most providers account for this lower reimbursement by shortening appointments so they can see more patients per hour/per day. In other words, it becomes a game of volume dentistry. In these kinds of offices, seeing a higher volume of patients is one of the only ways to make enough money to make up for lower reimbursements. Working faster in order to see more patients each day can lead to a diminished patient experience, but can also result in dental care that, while still clinically acceptable, might not be as high-quality or long-lasting. This faster treatment can also increase the risk for error and the need for more return visits to correct errors. It can also increase the likelihood of patients experiencing post-op sensitivity and discomfort.
On the contrary, out-of-network or non-contracted/direct care providers choose not to sign contracts with dental insurance carriers. In doing so, they remain free of the many restrictions imposed by these carriers, and can instead focus on their main priority - providing high-quality care and an exceptional experience to their patients. In these types of offices, providers are free to spend significantly more time with each patient, use higher quality techniques, materials and labs, and provide an overall more satisfactory experience. Many non-contracted providers see patients with dental insurance, and most are happy to help each patient to get the most from their coverage. However, it's important for patients to understand that while most insurance carriers will still pay non-contracted providers for providing care to a covered patient, they'll still often only pay the amount that they would otherwise a pay to a contracted provider. What this typically means for patients with insurance who choose to see a non-contracted provider is that there may be a difference between their dentist's full fee for a specific service and what their insurance will pay toward that service. In this case, the patient is ultimately responsible for paying any difference or, in other words, any amount not covered by their insurance. While these patients may pay somewhat more out-of-pocket for their care, they typically receive higher quality care with higher quality materials, and an overall much better dental experience.
It's important for all patients to realize that they have the freedom to choose either an in-network or out-of-network provider, regardless of which direction their dental insurance carrier wants them to go in. To be clear, it's not that an in-network or out-of-network provider is better than the other, but as with anything it's important for patients to fully understand the benefits and limitations of each so they can make an informed decision.
6. Quality vs. Quantity:
As mentioned above, insurance carriers often prioritize cost-saving measures over patient care. After all, they're in the business of making money for their executives and shareholders. They're not healthcare providers and have no real interest in how well or unwell patients are, as long as those patients pay for their premiums on time and hopefully use as little of their coverage as possible. Providers contracted with insurance carriers may face pressure to see a higher volume/quantity of patients and cut costs, which can lead to rushed appointments and compromised quality of care. Conversely, dentists who operate unrestricted, or outside of insurance networks, can spend significantly more time with each patient, offer more personalized treatment, and focus more on providing the highest quality care.
Embracing Direct Care Dentistry
At our privately-owned family practice, we've chosen not to contract with insurance carriers. By doing so, we join a growing number of dental and medical providers across the country who are focused on providing high quality healthcare and a better overall experience for our patients. Want to learn more about direct care dentistry and its many benefits to patients? Then be on the lookout for our next blog post!
Conclusion
While at first glance dental insurance might seem like a safety net, its limitations can often prevent patients from receiving the high-quality care they want and deserve. Understanding these limitations can help you to make more informed decisions about your dental and overall health.
At our practice, we're committed to providing exceptional dental care tailored to your needs, free from the constraints of traditional dental insurance. While it isn't always easy to do what we feel is right by our patients, your smiles are certainly worth it.
Please feel free to contact us if you have any questions or would like to learn more about the ins and outs of dental insurance or our direct care dentistry approach. We're here to help you achieve and maintain your healthiest, most radiant smile!
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